How the Successful Practice Manages the Five Key Areas of Compliance
by Dr. Steven J. Kraus, D.C., D.I.B.C.N., C.C.S.P., F.A.S.A.
Compliance affects every aspect of a practice, from who should have access to patient records to whether an X-ray machine is properly calibrated. Regulations exist at all levels of government—federal, state and local—and in the business sector. We shouldn’t assume that our current practices comply with regulations simply because we’ve been trained. We have to be diligent about updating our policies and refreshing our knowledge.
Many DC’s face challenges that result from not staying abreast of current regulations. And requirements such as employee harassment policies, internal chart audit programs and a host of other regulations may not be on the radar for recent graduates. Our schedules are hectic; it’s easy to leave a manual sitting on the shelf of the clinic manager’s office for years without updating it, or to forget recurrent staff training. But these activities help doctors be more successful by avoiding major fines and ensuring clinics are in compliance.
Managing a Robust Compliance Program
Maintaining a compliance program is no small task, but your practice will benefit in numerous ways, financially and otherwise. Most practices have established compliance programs in place, but those programs likely need to be updated or more detailed to be effective. Following are recommended steps to improve your compliance program:
Step one: Understand and adhere to your state’s Board of Chiropractic rules
In most states, two pieces of information govern your license: Practice Act and Board Rules. Secure copies of these documents and read them thoroughly. Rules are updated, modified or added annually. As chairman of the Iowa Board of Chiropractic, and voting delegate to the Federation of Chiropractic Licensing Boards, I can tell you that recent changes have been made in the areas of advertising, billing ethics, CA therapy rules, and continuing education requirements in many states.
Maintain a careful balance between your Board rules and Federal rules, such as those under the Health Insurance Portability and Accountability Act (HIPAA) or Centers for Medicare & Medicaid Services (CMS). For instance, some states require that records are kept for seven years, but HIPAA only requires six. You must be in compliance with both Federal and State rules, adhering to whichever is the greater requirement. You may be surprised to learn that you are in violation, if only because you were unaware of a change. But ignorance does not save you from a mark on your licensure records; consumers have greater access to information, and a licensure problem can hurt your credibility and your practice.
Step two: Establish a compliance program that supports your practice’s activities
Facility managementThis area includes all activities that affect your physical facility. Understanding and following the regulations established by agencies and laws is critical. For example:
• CLIA—If you perform certain lab tests, the Clinical Laboratory Improvement Amendments (CLIA) require that a set of guidelines is followed. Has your office been inspected and approved to perform laboratory tests? Do you have your certificate and fees paid? Are your services waived under CLIA regulations?
• OSHA—Exposure control to blood borne pathogens, X-ray chemistry and medical waste are under the Occupational Safety & Health Administration’s (OSHA’s) oversight. Hazard communication is required for all staff, including a written plan and training logs for staff. Building and fire safety also fall under OSHA. Are your written policies updated and in place? Has your staff been trained?
• Equipment—What equipment and therapy devices are used in your office? Does your equipment deliver correct dosages, high quality therapy and acceptable X-rays? For instance, most states require X-ray calibration documentation from the Department of Health, and other equipment may be regulated by state and federal agencies.
• Liability insurance—Are you covered if a patient trips and falls on your sidewalk, or gets injured on a piece of exercise equipment?
Clinic managementThis area includes your business activities, such as marketing, employee relations, billing and documentation.
• Employee relations—Have you reviewed the most recent guidelines from the Equal Employment Opportunity Commission? Is your practice required to offer time off under the Family and Medical Leave Act? What training must your employees receive regarding appropriate office behavior?
• Marketing—Did you know that offering a gift valued at $10 or more to a patient is considered an inducement by Medicare and violates marketing rules? Have you checked with your state Board to ensure that your legal clinic name is still valid under current requirements? Does your Board have advertising and claiming expertise rules?
• Documentation and billing—The purpose of compliance management in this category is to determine the accuracy of your existing activities, and to ensure that you are eligible for reimbursements. What is your error rate in terms of billing versus what is documented in the record? Does your documentation justify the services billed? Do your billing codes match what is contained in the record?
This area focuses on professional requirements, such as license renewal and malpractice protection:
• License renewal—Your state Board explains what requirements are necessary to keep your license current. Have you taken the necessary continuing education courses? Have your fees been paid?
• Malpractice—Most health insurance companies require a certain level of coverage. Your malpractice insurance carrier may offer additional coverage for audit-based legal expenses, corporation coverage and specialty services.
Step three: Review all existing logs and update them
Logs are required by numerous agencies and laws, especially OSHA, HIPAA and others. For example, your HIPAA manual must include staff training updates, information on storage and security of records and more; any changes or updates to the manual must be logged. With all compliance areas, a written document, policy or manual with current logs is critical—USE IT. If you have a manual but don’t actually use it, your goal of providing effective, quality care in a safe, professional environment is defeated.
Step four: Assign staff members to oversee various compliance areas
Some regulation requires the doctor to oversee compliance, and other areas, such as records compliance require someone other than the person who created the records to perform the compliance review. But where there is flexibility, others may serve you better for direct oversight. Require your staff delegates to submit a written report outlining quarterly compliance evaluations and results. Support them by sending them to training seminars, reinforcing the importance of internal training, and requiring employees to focus on compliance. Assign responsibilities to your most trustworthy and competent staff members.
Step five: Require recurrent training
As stated previously, training is critical to a robust and effective compliance program. Demonstrate leadership by attending trainings and sharing information with your team; host annual or quarterly sessions internally and adhere to an established schedule.
The Benefits of Compliance
While managing a compliance program may seem overwhelming and complex, the benefits far outweigh the challenges, as outlined below: Increased profitability—An effective compliance program can lead to increased profitability, as you identify deficiencies that are costing money, avoid expensive investigations, gain access to PPO panels and more. True story: I once worked with a client on a self-audit and he discovered a horrifying gaffe that uncovered lost income of more than $50,000 over five years. He had never personally conducted an audit and discovered that his progress exams were reflected in his charts, but the information on paper only occasionally made its way to billing. This error, which is typical with paper-based documentation systems, resulted in under-billing of nearly $600 per month for progress exams. Employee satisfaction and pride—A compliant practice is a trustworthy and safe practice in the eyes of employees. Numerous human resources consultants have shared results of surveys which conclude that a clinic with systems in place gives staff pride in their workplace because they know they are associated with a compliant, efficient clinic. Sure, employees enjoy rewards and benefits, accolades and respect, but they want training to be competent in an ethical practice that follows the rules. Maintaining a compliance program demonstrates that you care about safety and quality care. That attention to detail can be the difference between mediocre practices and successful ones. Improved image, patient satisfaction and practitioner satisfaction—Public records via Department of Health websites and other information sources can demonstrate your compliance, a consumer indicator that you are dedicated to quality. Patients want quality care and will believe your practice is likely to deliver it. Further, a strong compliance program will ultimately decrease stress for the doctor, who can focus on patient care rather than time-consuming investigations.
While concern about government involvement in our profession exists, regulations, guidelines, and laws were created for the safety of consumers, to protect us as doctors, and to ensure that healthcare ethics and quality are maintained. Now that chiropractic is more widely recognized, we have the full attention of regulatory agencies. In fact, the Office of the Inspector General has increased its Medicare auditing, with 40 percent more chiropractic audits anticipated in 2009. But a responsible compliance program, especially one that is fully integrated into your clinic, will help you manage audits, improve performance and enjoy a successful practice.